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"Detachment of the carinal hook following endobronchial intubation with a double lumen tube"
© Rocha et al; licensee BioMed Central Ltd. 2011
Received: 19 January 2010
Accepted: 28 October 2011
Published: 28 October 2011
Carinal hooks increases difficulty at endotracheal intubation. Amputation of the carinal hook during passage and malpositioning of the tube to the hook are some of the potential problems related with left-sided Carlens double lumen tube (DLT). This article reports an amputation of the hook during a difficult selective intubation and aimed at calling the attention to complications associated with DLTs and the importance of fiberoptic bronchoscopy.
A 68 year-old woman was scheduled for right-sided thoracotomy in whom blind DLT insertion was performed. Narrowed trachea causes difficulty in rotating the DLT 90° counter-clockwise. After carinal hook was noticed upon visual inspection of the DLT, fiberoptic bronchoscopy was used to remove the missing part (with the use of forceps) from the right mainstem bronchus.
Insertion of DLTs with carinal hook is associated with technical problems and potentially life-threatening hazards have discouraged their use. Fiberoptic evaluation and repositioning solves most of the problems. Although amputation of the carinal hook has not been previously reported, clinicians should be alert. This case report emphasizes the utility of the fiberoptic bronchoscopy in the operating theatre for placement, positioning and inspection of the carinal hook DLT.
Double-lumen tubes with fixed carinal hooks facilitated proper placement and minimized further tube advancement during positioning. However, potential problems and complications were associated with carinal hooks. These included a higher incidence of insertion difficulty, laryngeal trauma and amputation of the hook during placement [1, 2]. Several methods for proper placement and positioning of DLTs are available in [3–6]. We describe a case of a carinal hook's amputation after blind insertion of left-sided polyvinylchloride Carlens DLT (SUMI®, Portex Inc., Mexico). The foreign body was removed from the right mainstem bronchial lumen with a fiberoptic-guided technique and, although a successful outcome was achieved, we failed the placement of DLT with fiberoptic bronchoscopy.
Potential problems with carinal hook have been observed [1, 2], however this is the first case reported of amputation of the carinal hook in a 37F left-sided polyvinylchloride Carlens DLT (SUMI®, Portex Inc., Mexico).
The exact mechanism leading to the amputate ion of the carinal hook is obscure. Rigid structures, narrow passages and manufacturing defect are possible .
In this case, desaturation and resistance to manual ventilation have alerted to a probably malpositioned DLT. In fact, tracheal narrowing was visualized by conventional laryngoscopy and insertion of the DLT occurred with some difficulties. The potential cause for the hook detachment was a narrowed trachea. Prompt action to remove the airway foreign body by bronchoscopy solved the patient's problem without adverse consequences. Although fiberoptic bronchoscopy is the accepted standard for appropriate positioning and confirmation of DLT , it was not performed in the first attempt. No double-lumen tube positioning method is fail-safe and unsuccessful replacement of another DLT with the aid of fiberoptic bronchoscopy occurred.
The present case has demonstrated that carinal hooks can be hazardous. It also highlights the importance of the availability of fiberoptic equipment in the operating theatre to promote proper DLT positioning and inspection of the carinal hook DLT, to reconfirm that no amputation had occurred.
Assuming a manufacturing defect of the 37F left-sided polyvinylchloride Carlens DLT (SUMI®, Portex Inc., Mexico.), until now no answer regarding the event was given by the DLT company.
Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Written consent for publication was obtained from the patient or their relative.
- Wilson WC, Benumof JL: From Anesthesia for thoracic surgery. Edited by: Miller RD. 2005, Miller's Anesthesia. Philadelphia: Churchill Livingstone, 1847-1939. 6Google Scholar
- Al-Metwalli RR, Mowafi HA, Ismail SA: Double-Lumen Tube Placement Using a Retractable Carinal Hook: A Preliminary Report. Anesth Analg. 2009, 109 (2): 447-450. 10.1213/ane.0b013e3181ac6d78.View ArticlePubMedGoogle Scholar
- Campos JH, Hallam EA, Van Natta T, Kernstine KH: Devices for lung isolation used by anesthesiologists with limited thoracic experience: comparison of double-lumen endotracheal tube, Univent torque control blocker, and Arndt wire-guided endobronchial blocker. Anesthesiology. 2006, 104 (2): 261-266. 10.1097/00000542-200602000-00010.View ArticlePubMedGoogle Scholar
- Eagle CC: The relationship between a person's height and appropriate endotracheal tube length. Anaesth Intensive Care. 1992, 20 (2): 156-160.PubMedGoogle Scholar
- Chang PJ, Sung YH, Wang LK, Tsai YC: Estimation of the depth of left-sided double-lumen endobronchial tube placement using preoperative chest radiographs. Acta Anaesthesiol Sin. 2002, 40 (1): 25-29.PubMedGoogle Scholar
- Bahk JH, Oh YS: A new and simple maneuver to position the left-sided double-lumen tube without the aid of fiberobtic bronchoscopy. Anesth Analg. 1998, 86 (6): 1271-1275.PubMedGoogle Scholar
- Pollak Y, Kogan A, Grunwald Z: Double-lumen tube malfunction caused by carinal hook. Anesthesiology. 1995, 83 (3): 639-View ArticlePubMedGoogle Scholar
- Cohen E: Double-lumen tube position should be confirmed by fiberoptic bronchoscopy. Curr Opin Anaesthesiol. 2004, 17 (1): 1-6. 10.1097/00001503-200402000-00002.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2253/11/20/prepub
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